When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Determine apical pulse rate and rhythm.

Observe color and amount of urine.

Compare muscle strength bilaterally.

Assess strength of deep tendon reflexes.

Answer and Explanation

The Correct Answer is A

Choice A reason: This is the most important intervention because a high serum potassium level can cause cardiac dysrhythmias, which can be life-threatening. The nurse should monitor the client's heart rate and rhythm closely and report any changes or abnormalities to the healthcare provider.

Choice B reason: This is not the most important intervention because the color and amount of urine are not directly related to the serum potassium level. The nurse should assess the client's renal function and fluid balance, but these are not the priority assessments.

Choice C reason: This is also not the most important intervention because the muscle strength is not the most sensitive indicator of the serum potassium level. The nurse should evaluate the client's neuromuscular status and watch for signs of weakness or paralysis, but these are not the priority assessments.

Choice D reason: This is another incorrect intervention because the deep tendon reflexes are not the most reliable indicator of the serum potassium level. The nurse should check the client's reflexes and note any hyperreflexia or hyporeflexia, but these are not the priority assessments.

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Correct Answer is C

Explanation

Choice A reason: This is an incorrect statement as it implies that breaking eye contact is beneficial for the client. In fact, breaking eye contact may reduce the client's trust and rapport with the nurse. The nurse should maintain eye contact as much as possible and use verbal and nonverbal cues to show active listening.

Choice B reason: This is an incorrect statement as it implies that electronic documentation is mandatory for all interviews. In fact, electronic documentation is not a legal obligation, but a preferred method of recording the assessment data. The nurse should follow the facility's policy and procedure for electronic documentation and ensure the accuracy, completeness, and confidentiality of the record.

Choice C reason: This is the correct statement as it acknowledges the challenge of electronic documentation during an interview. The nurse may miss some important nonverbal cues from the client, such as facial expressions, gestures, or posture, while typing on the computer. The nurse should balance the time spent on the computer and the time spent on the client and use open-ended questions and reflective statements to elicit more information.

Choice D reason: This is an incorrect statement as it implies that electronic documentation is beneficial for the interview process. In fact, electronic documentation may interfere with the flow and quality of the interview. The client may feel rushed or ignored by the nurse's attention to the computer. The nurse should pace the interview according to the client's needs and preferences and use electronic documentation as a tool, not a barrier.

A. Consult with the dietitian to learn if the client is allowed to drink coffee. B. Remind the client that no milk or creamer can be added to the coffee. C. Determine which member of the nursing staff brought the cup of coffee to the client. D. Remove the coffee from the tray, advising the client that it is not included in the diet.

Correct Answer is B

Explanation

Choice A reason: Consulting with the dietitian to learn if the client is allowed to drink coffee is not the best action to take. The nurse should already know the components of a clear liquid diet, which do not include coffee. Coffee is a stimulant that can irritate the gastrointestinal tract and interfere with the healing process.

Choice B reason:This is the correct action. A clear liquid diet allows for transparent liquids that leave no residue, such as black coffee. Adding milk or creamer would render the coffee opaque, making it unsuitable for a clear liquid diet. Therefore, it's appropriate to remind the client to consume the coffee without any additives.

Choice C reason: Determining which member of the nursing staff brought the cup of coffee to the client is not a priority action to take. The nurse should focus on the client's safety and well-being, not on assigning blame or finding fault. The nurse can address the issue with the staff later, after ensuring the client's needs are met.

Choice D reason: Removing the coffee is unnecessary, as black coffee is permitted on a clear liquid diet. Instead, the nurse should ensure the client understands not to add any prohibited substances like milk or creamer.

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When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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